[Congressional Record (Bound Edition), Volume 147 (2001), Part 19]
[Senate]
[Pages 26275-26276]
[From the U.S. Government Publishing Office, www.gpo.gov]



               VA COMMENDED FOR PATIENT SAFETY INITIATIVE

  Mr. ROCKEFELLER. Mr. President, today I am proud to highlight the 
recognition given to the Department of Veterans Affairs for the high 
level of attention they have paid to patient safety in recent years.
  The Institute for Government Innovation at Harvard University has 
announced that VA's National Center for Patient Safety (NCPS) will be 
one of five winners of the annual Innovations in American Government 
awards. An article in yesterday's Washington Post brings this 
achievement to national attention and details why VA's Center was the 
only federal recipient of the award.
  It's apparent that the NCPS has cultivated a culture within VA that 
promotes communication and therefore enables health care staff to feel 
more comfortable about reporting medical errors or even concerns that 
they have about patient safety. VA launched this initiative in 1998, 
but it received a major push in 1999 when the Institute

[[Page 26276]]

of Medicine released a report estimating that 44,000 to 98,000 
Americans die each year due to medical mistakes.
  This award demonstrates how VA has pioneered the establishment of the 
type of culture which must exist. According to the article, many health 
care providers in the private sector have started to model their 
patient safety models around that of the NCPS. This was a driving force 
behind the Institute for Government Innovation's decision to recognize 
VA's efforts by giving them this honor.
  For a long time now, I have pushed VA to pay closer attention to 
patient safety, as it has been an issue of concern in the past. This is 
why I am glad to finally see VA on the cutting edge of patient safety, 
and being acknowledged for it. Our veterans deserve nothing less than 
highest standards of health care.
  I ask unanimous consent that an article from The Washington Post, 
detailing VA's patient safety program and the award, be printed in the 
Record.
  There being no objection, the article was ordered to be printed in 
the Record, as follows:

               [From the Washington Post, Dec. 13, 2001]

           VA Medical System To Get Harvard Innovation Award


         Reporting, Handling of Health Care Errors To Be Cited

                             (By Ben White)

       The Department of Veterans Affairs health care system, long 
     derided as a bloated bureaucratic mess, will be singled out 
     for praise today for its efforts to improve the way medical 
     errors and close calls are reported by health care workers 
     and handled by hospital administrators.
       VA's National Center for Patient Safety (NCPS) will be the 
     only federal program among five winners of the annual 
     Innovations in American Government awards from the Institute 
     for Government Innovation at Harvard University. The awards 
     are to be announced today.
       Gail Christopher, executive director of the institute, said 
     the NCPS is helping foster a ``healthier culture of 
     communication'' in which health care workers at VA's 173 
     medical centers are far more likely to report mistakes or 
     close calls than in years past.
       ``It's sort of a breath of fresh air for workers who are 
     used to being in an adversarial or litigious climate,'' 
     Christopher said. ``It meets a basic set of human needs, to 
     strive for excellence while at the same time acknowledging 
     the potential for human error. Its genius is really its 
     simplicity.''
       VA officials say the program, begun in 1998, produced a 30-
     fold increase in the number of accident reports in just 16 
     months and a 900-fold increase in the number of reported 
     close calls over the same period. These numbers reflect not 
     an increase in mistakes, they say, but rather a big jump in 
     the willingness of doctors, nurses and other workers to 
     report problems.
       The agency began to focus on the issue after a 1999 report 
     by the Institute of Medicine estimated that 44,000 to 98,000 
     Americans die each year as a result of medical errors.
       VA Secretary Anthony J. Principi said NCPS has created a 
     centralized mistake-reporting system that helps staff analyze 
     and address repeat problems while also establishing a new 
     culture in which the emphasis is on addressing the root 
     causes of errors rather than punishing those who make them.
       ``We look at entire systems now, not just, say, a nurse who 
     [makes a mistake] because she is pressed for time,'' Principi 
     said in an interview yesterday. He noted, however, that VA 
     will still punish anyone who ``intentionally and criminally 
     hurts a patient.''
       In addition to the improved, confidential mistake-reporting 
     system, NCPS has set up a voluntary external system, modeled 
     after a NASA program, that allows any individual to report 
     medical mistakes or close calls anonymously.
       NCPS Director James P. Bagian said the anonymous system 
     serves as a safety valve to make sure serious problems that 
     VA health workers might feel uncomfortable reporting, even 
     confidentially, do not slip unnoticed.
       Bagian cited a flawed pacemaker and a potentially deadly 
     ventilator as examples of problems the NCPS regime has helped 
     identify and correct. But he said the biggest success has 
     been the change in culture. VA health care workers now know 
     they will be identified publicly and punished only if they 
     deliberately cause harm to a patient, according to Bagian. If 
     a worker simply makes a mistake, he can report it 
     confidentially and a team will assess the case, addressing 
     the cause of the error rather than the individual 
     responsible.
       ``We no longer focus on whose fault it is,'' Bagian said, 
     noting that the handbook explaining the new approach is 
     written in plain English, rather than in the legalese of the 
     past. ``Instead we ask: What happened? How did it happen? And 
     what can we do to prevent it in the future?''
       The award carries a $100,000 grant to help VA further the 
     program and let others know about it. Harvard's Christopher 
     said VA earned the award in part because so many private 
     health care and hospital companies are already seeking to 
     emulate NCPS.
       ``Clearly, the problem this program addresses is of 
     monumental significance,'' she said. ``and word has spread 
     rapidly within the health care community.''

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